A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Master of Medicine in the branch of Internal Medicine, Johannesburg, 2014 / Objective: To evaluate and compare any differences in control, i.e. HbA1C, total cholesterol, BP and BMI in a single group of Type-2 diabetes patients during two time periods, i.e. before and after specialist-supervised care. In addition, to describe differences in the use of anti-platelet and statin therapy for primary cardiovascular prophylaxis. Methods: Patients were recruited from the Diabetes Clinic at Chris Hani Baragwanath Academic Hospital (CHBAH) and the audits of two separate time periods were conducted. The first audit recorded standard of care delivered by registrars from January 2005 to December 2007. The second audit recorded care after the introduction of specialist-supervised care from September 2009 to September 2012. The patients were all insulin-requiring and were required to be seen for at least 24 months during both audit periods. The first recorded HbA1C in (i) 2005 and (ii) from September 2009 triggered the inception of a patient’s assessment periods. Data for at least 80% of parameters had to be available for a patient to be included in the audit. Results: This study showed significant differences using ANCOVA comparing final values for each audit after adjustment for their respective baseline values in respect of HbA1C (p<0.000), SBP (p<0.012) and BMI (p<0.001) after the implementation of an endocrinologist-supervised clinic. The percentage of patients reaching guideline targets, and the use of aspirin and statins, improved as well. Conclusion: This study showed a difference in the level of care delivered by the endocrinologist-supervised clinic as opposed to one which was led by registrars. However, other factors may have contributed to the outcomes, most notably that the consultation time with each patient was longer after the introduction of expert supervision in 2009.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Internal Medicine Johannesburg, 2014 / Background Diabetes is a global epidemic. The International Diabetes Federation estimates that there are at least 285 million diabetics worldwide and this is estimated to grow to over 440 million by 2030 1 . A study was conducted at the Helen Joseph Hospital Diabetic clinic in an attempt to identify predictors of glycaemic control and to compare the level of care to the 2012 Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) guidelines. Methods Patients were recruited from the Helen Joseph Hospital Diabetic clinic. To be included the patient had to be part of the coloured (mixed race) community, be willing to give informed consent, be older than 18 years, have an HBA1C taken within 6 months, have a diagnosis of Type 2 diabetes mellitus and be a clinic attendee for at least 1 year. Pregnant patients, Type 1 diabetic patients, patients with a psychotic disorder or aphasia were excluded. Data collection consisted of face-to-face interviews, review of treatment, medication knowledge evaluation, a short examination and collection of recent blood results. Statistical analysis was done by stratifying patients into two groups by using the mean HBA1C. Variables with a p < 0.1 from this analysis were used in a logistic regression model. In addition, the correlation between continuous variables were tested. A comparison was made between the level of care and the 2012 SEMDSA guidelines. v Results A total of 100 patients were recruited into the study. The mean age was 62.8 years with mean duration of diabetes of 15.8 and clinic attendance of 10.9 years. The group had very poor education level and the median income of R1200 per month was also low. The mean HBA1C was found to be 9.74%, well above the target recommended by SEMDSA. Knowledge of diabetes with respect to management and complications was very poor. Age > 50 years (OR 0.372 CI 0.06-2.26), estimated glomerular filtration rate ≥ 60 ml/min/1.73m2 (OR 0.90 CI 0.25-3.27), experiencing a microvascular complication (OR 0.73 CI 0.11-5.07) or any other diabetic complication (OR 0.56 CI 0.07-4.38) and having experienced a hypoglycaemic episode (OR 0.31 CI 0.09-1.10) predicted better glycaemic control. Duration of diabetes < 10 years (OR 1.36 CI 0.37-5.02), diastolic blood pressure ≥ 70 mmHg (OR 2.80 CI 0.80-9.78), aspirin dosage ≥ 150 mg daily (OR 6.47 CI 1.60-26.05), simvastatin dosage = 40 mg daily (OR 2.35 CI 0.31-18.10) and body mass index > 25 kg/m2 (OR 1.09 CI 0.49-2.41) all predicted a poorer glycaemic result. HBA1C was found to positively correlate with diastolic blood pressure (p = 0.0024, r = 0.31). Systolic blood pressure positively correlated with diastolic blood pressure (p < 0.0001, r = 0.56). Apart from correlating with systolic blood pressure and HBA1C, diastolic blood pressure also positively correlated with the triglyceride level (p = 0.0003, r = 0.36). Positive correlations between total cholesterol, triglycerides, HDL-C and LDL-C were found. As expected, body mass index and waist circumference correlated positively (p < 0.0001, r = 0.82). Level of care was not at the level recommended by the 2012 SEMDSA guidelines. Only 6% of patients met the waist circumference goal. Only 15% of patients achieved blood v i pressure goal. Most of the patients (86%) who qualified for aspirin did not receive it. In the group of patients receiving aspirin 33% did not qualify. According to the SEMDSA guidelines, most of the patients not receiving a statin (90%) should have been on statin therapy. Only 23.5% of patients on statins were at lipid goal. The frequency of laboratory testing did not meet SEMDSA guidelines. There were 31 (31%) patients without a urea, creatinine and electrolyte test for the previous year and 37 (37%) patients without a lipogram for the previous year. Only 21 patients had a listed urine albumin/creatinine ratio and only 33% of these had been done in the previous year. Conclusions Various new variables were identified in the search for predictors of glycaemic control. It was surprising to find that education level, monthly income, smoking status and knowledge of diabetes did not have a statistical impact on glycaemic control. Increased age, duration of diabetes, glomerular filtration rate, hypoglycaemic frequency and diabetic complications experienced were associated with improved glycaemic control. Increased diastolic blood pressure, aspirin dosage, statin dosage and body mass index were associated with worse glycaemic control. The standard of care in the clinic was found on the whole to be inferior to the level of care recommended by SEMDSA.

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2005. / Härtill 5 uppsatser.

Thesis (M.S.)--University of Wisconsin, School of Nursing, 1973. / eContent provider-neutral record in process. Description based on print version record.

Yang Tao. / "November 2000." / Thesis (Ph.D.)--Chinese University of Hong Kong, 2000. / Includes bibliographical references (p. 136-152). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web. / Abstracts in English and Chinese.

Thesis (Ph. D.)--University of Washington, 2001. / Vita. Includes bibliographical references (leaves 152-175).

Proefschrift Universiteit van Amsterdam. / Met lit. opg. - Met samenvatting in het Nederlands.

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2006. / Härtill 4 uppsatser.

Proefschrift Maastricht. / Met lit. opg. - Met samenvatting in het Nederlands.

Proefschrift Universiteit Maastricht. / Met bibliogr., lit. opg. - Met samenvatting in het Nederlands.